• This manual is not a substitute for consultation with an appropriate specialist.
• The contents of this manual have been developed through consensus of a Provincial Tumour Group. Please note the various update dates for each section as some of the content of the manual may not be up to date.

Revised 19 April 2010

1. Diagnosis

Diagnostic Pathology

1. History and physical examination
2. Clinical staging
3. Culture of lesion
4. CT scan pelvis (invasive lesions)
5. Chest X-ray if indicated

2. Staging

Classification Criteria

T - Primary Tumour

• TX: Primary tumour cannot be assessed
• T0: No evidence of primary tumour
• Tis: Carcinoma in situ
• Ta: Non-invasive verrucous carcinoma
• T1: Tumour invades subepithelial connective tissue
• T2: Tumour invades corpus spongiosum or cavernosum
• T3: Tumour invades urethra or prostate
• T4: Tumour invades other adjacent structures

N - Regional Lymph Nodes

Regional Nodes: Superficial and deep inguinal, and pelvic nodes.

• NX: Regional lymph nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1: Metastasis in a single superficial inguinal lymph node
• N2: Metastasis in multiple or bilateral superficial inguinal nodes
• N3: Metastasis in deep inguinal or pelvic lymph node(s), unilateral or bilateral

M - Distant Metastasis

• MX: Presence of distant metastasis cannot be assessed
• M0: No distant metastasis
• M1: Distant metastasis

Staging Diagram

3. Management

Tis, Ta N0 M0 Stage 0

Excision with an adequate margin. Laser therapy in selected cases.

T1 N0 M0 Stage I and T2 N0 M0 early Stage II

1. Circumcision for preputial lesions
2. Partial penectomy (2 cm proximal to the lesion)
3. Radiotherapy: external beam or brachytherapy

In patients who have undergone partial penectomy, we recommend short-term antibiotic therapy and reassessment in six weeks. Regional superficial node dissection recommended for T2 or greater lesions and non-palpable lymph nodes. If after six weeks, nodes are palpable in an inguinal region, we recommend modified bilateral inguinal lymph node dissection. Regional XRT for palliation of unresectable lymph nodes. If the node biopsy is negative, no further therapy is indicated.

Penile Brachytherapy - organ preservation alternative

Patient Selection Criteria:

• Clinical stage: T1N0 and T2N0 (no clinically palpable lymph nodes)
• Maximal tumour diameter 4cm
• Extension of tumour onto penile shaft is a contra-indication to brachytherapy
• Grade 1, 2 (well to moderately differentiated tumours)
• Grade 3 and bilateral groin node dissection negative for nodal involvement
• Patients must be circumcised
• Good general condition

Staging:

• For T1N0 well differentiated tumours routine CT scan may not be required
• For all others (T1 N0 grade 2, T2N0 any grade) a CT is recommended for nodal staging
• Staging groin dissection recommended for all T2, and T1 Grade 3 tumours

Procedure:

Implant is performed in the OR under general anaesthetic. Volume implant is done using 4-10 17 gauge sterile needles held in place with 2 parallel acrylic templates. Patients remain in hospital for minimum 5 days to receive radiation treatment using the needle implant and HDR technique. Mild analgesia (Acetaminophen or Tylenol #3) and DVT prophylaxis is administered to all patients.

Lymph nodes are managed by surveillance (clinical exam, periodic CT scans) or prophylactic dissection as above.

Outcomes:

Functional organ preservation rate at 2 years is 89% and at 5 years, 85% (Crook at all. Int. J. radiation oncology Biol. Phys. Vol 62, No2.pp460, 2005 ). Surgery is reserved for local failures.

Side effects:

Moist desquamation of the skin/glans penis is expected after the procedure. This heals in 2-3 months. Urethral stenosis rate is 1—15 %. Radiation soft tissue necrosis rate is about 15%. Conservative or hyperbaric oxygen management is appropriate, and surgery reserved for conservative management failure.

Procedure is available at the Vancouver Centre (VC) and at the Center for Southern Interior in Kelowna (CSI).

T1 N1 Stage II and T2 N2 Stage III

1. partial penectomy or radical penectomy
2. therapy for a short period then reassessment at six weeks. At that time all patients should have a sentinel node biopsy. If the biopsy is positive, then bilateral ilioinguinal node dissection should be performed. Patients with positive lymph nodes in the specimen may be considered for pelvic radiotherapy
3. patients whose medical condition does not permit surgery or where the patient does not wish to have surgery, radiotherapy to the pelvis and inguinal nodes is an alternative treatment

T3 N0 Stage III and T4 or N3 or M1 Stage IV

Exenterative surgery in select cases. Palliative radiotherapy and/or chemotherapy.

4. Follow-up

Following the completion of treatment, all patients need to be monitored for potential recurrence of cancer and complications of therapy. This is needed both for management of the individual patient (where early detection would improve outcome), and to permit periodic review and improvement of current treatment policy.

The patient should be seen monthly for one year after treatment of the primary disease to assess the inguinal regions, if these have not been treated initially. Thereafter:

• Year 2 = q 3 months
• Year 3 = q 4 months
• Year 4-5 = q 6 months

Often it is felt appropriate to share follow up with the family doctor (and/or the urologist), in which case it is important for the patient to be clear who is responsible for certain aspects of the disease, e.g. symptom control by the family doctor, with advice from the BC Cancer Agency at the doctor's request.

Notification is requested in the event of any of the following:

1. recurrence at the primary site (particularly in patients with clinically localized disease treated with surgery and/or radiotherapy)
2. at regional or distant sites
3. of therapy especially if acute requiring hospitalization, or chronic and symptomatic
4. with primary cause and whether cancer or treatment contributed

The event, date, and evidence where appropriate should be sent to the Agency chart where it will come to the attention of the oncologist, and will be available for periodic review by the tumour group. This information is requested annually for patients no longer followed at the BC Cancer Agency.

Published August 2002

1. Staging

Staging (BC Cancer Agency)

• Stage A 
• A1 Disease localized to scrotum 
• A2 Local extension involving adjacent structures (penis, perineum, testis, cord, pubis) but without evident metastases 
• Stage B
  Regional metastases - resectable (inguinal or ilioinguinal) 
• Stage C
  Regional metastases, non-resectable 
• Stage D
  Distant metastases (beyond regional nodes)
  

Staging Diagram

Investigations for Staging

1. Chest X-ray
2. Culture
3. CT scan in selected cases

2. Management

Carcinoma of the scrotum occurs very rarely in our population. Careful review and consideration should be given before any therapy is initiated.

Stage A

Wide local excision (testis and cord left).

Stage B

Wide local excision (testis and cord left). Staged groin dissection (inguinal when clinically positive).

Stage C & D

Palliative chemotherapy and/or radiotherapy.

3. Follow-Up

(See Skin Cancer recommendations, Non-melanoma)​

Following the completion of treatment, all patients need to be monitored for potential recurrence of cancer and complications of therapy. This is needed both for management of the individual patient (where early detection would improve outcome), and to permit periodic review and improvement of current treatment policy.

Often it is felt appropriate to share follow up with the family doctor (and/or the urologist), in which case it is important for the patient to be clear who is responsible for certain aspects of the disease, e.g. symptom control by the family doctor, with advice from the BC Cancer Agency at the doctor's request.

Notification is requested in the event of any of the following:

1. Local recurrence at the primary site (particularly in patients with clinically localized disease treated with surgery and/or radiotherapy)
2. Metastasis at regional or distant sites
3. Complications of therapy especially if acute requiring hospitalization, or chronic and symptomatic
4. Death with primary cause and whether cancer or treatment contributed

The event, date, and evidence where appropriate should be sent to the Agency chart where it will come to the attention of the oncologist, and will be available for periodic review by the tumour group. This information is requested annually for patients no longer followed at the BC Cancer Agency.

Published August 2002

1 Staging

Classification Criteria

T - Primary Tumour

• TX: Primary tumour cannot be assessed
• T0: No evidence of primary tumour
• Ta: Non-invasive papillary carcinoma
• Tis: Carcinoma in situ
• T1: Tumour invades subepithelial connective tissue
• T2: Tumour invades muscularis
• T3: (Renal pelvis) Tumour invades beyond muscularis into peripelvic fat or renal parenchyma
  (Ureter) Tumour invades beyond muscularis into periureteric fat
• T4: Tumour invades adjacent organs or through the kidney into the perinephric fat

N - Regional Lymph Nodes

The regional lymph nodes are the hilar, abdominal para-aortic, paracaval and, for ureter, intrapelvic irrespective of laterality. Laterality does not affect the N classification.

• NX: Regional lymph nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1: Metastasis in a single node 2 cm or less in greatest dimension
• N2: Metastasis in a single node greater than 2 cm but not more than 5 cm in greatest dimension, or multiple lymph nodes, none more than 5 cm in greatest dimension
• N3: Metastasis in a lymph node more than 5 cm in greatest dimension

M - Distant Metastasis

• MX: Presence of distant metastasis cannot be assessed
• M0: No distant metastasis
• M1: Distant metastasis

Staging Diagram

Investigations for Staging

1. History and physical examination
2. Intravenous pyelogram
3. Chest X-ray
4. Urinalysis and culture
5. Urine cytology
6. Cystoscopy and retrograde pyelograms
7. In special cases where diagnosis is still in doubt, brush biopsy and/or basket biopsy
8. CT scan
9. Ureteroscopy

2. Management Policies

T1-3 N0 M0

Nephroureterectomy with cuff of bladder ± regional lymph node dissection for staging. T1N0M0 tumours, specifically low grade lesions, ureteroscopic treatment would seem appropriate for selected circumstances.

Distal ureteral lesions may be considered for ureterectomy and reimplantation. Cystoscopy and biopsy of suspicious bladder lesions should be performed before extirpative surgery of the upper ureteral lesion.

Treatment: nephroureterectomy with cuff of bladder ± regional lymph node dissection for staging.

T4 N0 M0

1. Palliative nephrectomy or
2. Palliative radiotherapy

T1-3 N1-3 M0-1

Selected patients with more advanced disease by virtue of more extensive nodal involvement or dissemination may be considered for palliative chemotherapy and/or radiation

In cases with carcinoma of the renal pelvis or ureter in a solitary kidney or in patients who have had multiple recurrences after conservative therapy, special treatment modalities may be indicated, depending on patient preference and Agency consultation.

3. Follow-Up

Following the completion of treatment, all patients need to be monitored for potential recurrence of cancer and complications of therapy. This is needed both for management of the individual patient (where early detection would improve outcome), and to permit periodic review and improvement of current treatment policy.

1. For patients who have received radiotherapy, one month post-treatment appointment at the Agency.
2. Regular cystoscopy and examination by urologist six-monthly for two years, thereafter annually as indicated.

Often it is felt appropriate to share follow up with the family doctor (and/or the urologist), in which case it is important for the patient to be clear who is responsible for certain aspects of the disease, e.g. symptom control by the family doctor, with advice from the BC Cancer Agency at the doctor's request.

Notification is requested in the event of any of the following:

1. Local recurrence at the primary site (particularly in patients with clinically localized disease treated with surgery and/or radiotherapy)
2. Metastasis at regional or distant sites
3. Complications of therapy especially if acute requiring hospitalization, or chronic and symptomatic
4. Death with primary cause and whether cancer or treatment contributed

The event, date, and evidence where appropriate should be sent to the Agency chart where it will come to the attention of the oncologist, and will be available for periodic review by the tumour group. This information is requested annually for patients no longer followed at the BC Cancer Agency.

Published August 2002

1. Staging

Classification Criteria

T - Primary Tumour

• TX: Primary tumour cannot be assessed
• T0: No evidence of primary tumour

Urethra (male and female)

• Tis: Carcinoma in situ
• Ta: Non-invasive papillary, polypoid or verrucous carcinoma
• T1: Tumour invades subepithelial connective tissue
• T2: Tumour invades any of the following: corpus spongiosum, prostate, periurethral muscle
• T3: Tumour invades any of the following: corpus cavernosum, beyond prostatic capsule, anterior vagina, bladder neck
• T4: Tumour invades other adjacent organs

N - Regional Lymph Nodes

Regional nodes: inguinal and pelvic irrespective or laterality.

• NX: Regional lymph nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1: Metastasis in a single node 2 cm or less in greatest dimension
• N2: Metastasis in a single node more than 2 cm in greatest dimension, or multiple lymph nodes

M - Distant Metastasis

• MX: Presence of distant metastasis cannot be assessed
• M0: No distant metastasis
• M1: Distant metastasis

Stage grouping:

• 0a: Ta N0 M0
• Ois: 
• Tis N0 M0
• Tis pu N0 M0
• Tis pd N0 M0
• I: T1 N0 M0
• II: T2 N0 M0
• III: 
• T1-2 N1 M0
• T3 N0-1 M0
• IV: 
• T4 N0-1 M0
• Any T N2 M0
• Any T Any N M1

Staging Diagram

Investigations for Staging

General

1. History and physical examination
2. Urinalysis and culture

For extent of local disease

1. EUA
2. CT scan if necessary

To exclude proximal disease

1. IVP
2. Cystoscopy +/- retrogrades

For disseminated screen

1. Bone scan with suggestive symptoms
2. LFTs
3. CT to evaluate nodes

2. Management

Primary carcinoma of the urethra developing in a patient who has neither a concomitant nor antecedent history of bladder cancer is rare. The malignancy commonly involves the entire urethra, although may be limited to the distal urethra and the series in the literature are small. Treatment must be individualized and referral for multi-disciplinary review is recommended.

In series using surgery or radiation therapy alone, the results have been disappointing, leading to recommendations of preoperative radiation and surgery in select patients with stage T2 or greater lesions.

Stage 0, I Anterior Urethra

1. Interstitial brachytherapy
2. Well differentiated tumours of the distal third may be managed by surgical excision.

Posterior Urethra

External beam radiation to draining lymphatics plus boost or local brachytherapy to tumour.

Stage II, III

1. Preoperative radiation to primary tumour and draining lymphatics followed by radical cystourethrectomy at six to eight weeks
   or
2. Radical radiation therapy using external beam to primary tumour and draining lymphatics with boost to local tumour volume; surgical salvage for recurrence.

Stage IV

Palliative therapy as indicated.

3. Follow-up

Following the completion of treatment, all patients need to be monitored for potential recurrence of cancer and complications of therapy. This is needed both for management of the individual patient (where early detection would improve outcome), and to permit periodic review and improvement of current treatment policy.

Follow up will be primarily by the urologist and will include urethrocystoscopy where relevant:

• Year 1 = q 3 months
• Year 2 = q 4 months
• Year 3-4 = q 6 months
• Year 5+ =annually

Often it is felt appropriate to share follow up with the family doctor (and/or the urologist), in which case it is important for the patient to be clear who is responsible for certain aspects of the disease, e.g. symptom control by the family doctor, with advice from the BC Cancer Agency at the doctor's request.

Notification is requested in the event of any of the following:

1. Local recurrence at the primary site (particularly in patients with clinically localized disease treated with surgery and/or radiotherapy)
2. Metastasis at regional or distant sites
3. Complications of therapy, especially if acute requiring hospitalization, or chronic and symptomatic
4. Death with primary cause, and whether cancer or treatment contributed

The event, date, and evidence where appropriate should be sent to the Agency chart where it will come to the attention of the oncologist, and will be available for periodic review by the tumour group. This information is requested annually for patients no longer followed at the BC Cancer Agency.

​Published August 2002

1. Diagnosis

Diagnostic Pathology

1. History and physical
2. Urethroscopy, cystoscopy, examination under anesthesia
3. IVP
4. CT scan pelvis
5. TUR biopsy is preferable to open biopsy
6. Excisional biopsy or needle biopsy of inguinal lymph node metastases

2. Staging

Classification Criteria

T - Primary Tumour

• TX: Primary tumour cannot be assessed
• T0: No evidence of primary tumour

Urethra (male and female)

• Tis: Carcinoma in situ
• Ta: Non-invasive papillary, polypoid or verrucous carcinoma
• T1: Tumour invades subepithelial connective tissue
• T2: Tumour invades any of the following: corpus spongiosum, prostate, periurethral muscle
• T3: Tumour invades any of the following: corpus cavernosum, beyond prostatic capsule, anterior vagina, bladder neck
• T4: Tumour invades other adjacent organs

Transitional cell carcinoma of prostate (prostatic urethra)

• Tis pu: Carcinoma in situ, involvement of prostatic urethra
• Tis pd: Carcinoma in situ, involvement prostatic ducts
• T1: Tumour invades subepithelial connective tissue
• T2: Tumour invades any of the following: prostatic stroma, corpus spongiosum, periurethral muscle
• T3: Tumour invades any of the following: corpus cavernosum, beyond prostatic capsule, bladder neck (extra-prostatic extension)
• T4: Tumour invades other adjacent organs (invasion of the bladder)

N - Regional Lymph Nodes

Regional nodes: inguinal and pelvic irrespective or laterality.

• NX: Regional lymph nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1: Metastasis in a single node 2 cm or less in greatest dimension
• N2: Metastasis in a single node more than 2 cm in greatest dimension, or multiple lymph nodes

M - Distant Metastasis

• MX: Presence of distant metastasis cannot be assessed
• M0: No distant metastasis
• M1: Distant metastasis

Staging Diagram

3. Management

Tumours of the male urethra are very rare and their treatment is complex and controversial. Multi-disciplinary assessment is needed before commencement of treatment.

1. Anterior tumours that can be widely excised by total or partial penectomy can usually be controlled locally
2. Periurethral infiltration in posterior tumours accounts for high incidence of local recurrence after their excision
3. One third of posterior tumours have invaded pubic rami
4. Inferior pubic rami must be excised to prevent otherwise virtual certainty of local recurrence
5. Radiation alone does not control posterior tumours
6. For one half of posterior tumours only palliative treatment possible

Specific recommendations according to anatomic location

Anterior tumours

1. Partial penectomy when residual urethra long enough to direct urinary stream
2. Total penectomy and perineal urethrostomy when partial penectomy not applicable
3. Staged therapeutic groin dissections when inguinal lymph node metastases clinically present

Posterior tumours

Options include:

1. Radical radiotherapy
2. Radical cystectomy, penectomy, partial scrotectomy (+ bilateral orchiectomy), with en bloc excision of inferior pubic rami and bilateral pelvic lymphadenectomy with or without preoperative radiation
3. Staged therapeutic groin dissection for inguinal lymph node metastases
4. Palliative therapy : Surgery or radiation as indicated

4. Follow-up

Following the completion of treatment, all patients need to be monitored for potential recurrence of cancer and complications of therapy. This is needed both for management of the individual patient (where early detection would improve outcome), and to permit periodic review and improvement of current treatment policy.

Follow up will be primarily by the urologist and will include urethrocystoscopy where relevant:

• Year 1 = q 3 months
• Year 2 = q 4 months
• Year 3-4 = q 6 months
• Year 5+ =annually

Often it is felt appropriate to share follow up with the family doctor (and/or the urologist), in which case it is important for the patient to be clear who is responsible for certain aspects of the disease, e.g. symptom control by the family doctor, with advice from the BC Cancer Agency at the doctor's request.

Notification is requested in the event of any of the following:

1. Local recurrence at the primary site (particularly in patients with clinically localized disease treated with surgery and/or radiotherapy)
2. Metastasis at regional or distant sites
3. Complications of therapy especially if acute requiring hospitalization, or chronic and symptomatic
4. Death with primary cause and whether cancer or treatment contributed

The event, date, and evidence where appropriate should be sent to the Agency chart where it will come to the attention of the oncologist, and will be available for periodic review by the tumour group. This information is requested annually for patients no longer followed at the BC Cancer Agency.